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HAZARDOUS MATERIALS
HAZARDOUS MATERIALS INVENTORY — CHEMICAL DESCRIPTION
one page per material per building orarft
❑ADD []DELETE ❑REVISE 200
Page _of_
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
PAUL'S DRY CLEANERS
CHEMICAL LOCATION 201
CHEMICAL LOCATION CONFIDENTIAL EPCRA 202
;Iding.
1
❑ YES
FACILITY ID #TF
A 0 0 0 5 1 0 3
MAP# (optional) 203
GRID# (optional) 204
01
62
II. CHEMICAL INFORMATION
CHEMICAL NAME 205
TRADE SECRET Yes 206
Hydrocarbon Based Solvent
If Subject to EPCPA, refer to instructions
COMMON NAME 207
Hydrocarbon Dry Cleaning Solvent
208
EHS* ❑ Yes
CAS# 209
*If EHS is "Yes", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 210
Combustible Liquid, Class II (1.1 II)
HAZARDOUS MATERIAL
TYPE (Check one item only) Oa PURE Ob. MIXTURE Oc. WASTE 211
RADIOACTIVE ❑Yes 212
213
CURIES
PHYSICAL STATE
(Check one item only) O a SOLID Ob LIQUID O c. GAS
2152t4 LARGEST CONTAINER
150.0
FED HAZARD CATEGORIES - PHYSICAL O FLAMMABLE GAS TINDER PRESSURE ❑ EXPLOSIVE ❑ SELF HEATING
(check all that apply) ❑ PYROPHORIC ❑OXIDIZER [:]ORGANIC PEROXIDE [:]SELFREACTIVE ❑PYROHORIC GAS ❑CORROSIVE TO METAL
❑ CONTACT WATER EMITS FLAMMABLE GAS ❑ COMBUSTABLE TO DUST 2] HAZARD NOT OTHERWISE CLASSIFIED
FED HAZARD CATEGORIES -HEALTH: ❑CARCIGONECITY ❑ ACUTE TOXICITY []REPRODUCTIVE TOXICITY []SKIN CORROSION OR IRRITATION
(check all that apply) ❑ RESPIRATIORY OR SKIN SENSITIZATION ❑ SERIOUS EYE DAMAGE OR EYE IRRIATIION ❑ SPECIFIC TAGET ORGAN TOXICITY
❑ ASPIRATION HAZARD ❑ GERM CELL MUTAGENICITY ❑ SIMPLE ASPHYXIANT 2] HAZARD NOT OTHERWISE CLASSIFIED
AVERAGE DAILY AMOUNT 217
MAXIMUM DAILY AMOUNT 2t 8
ANNUAL WASTE AMOUNT 219
STATE WASTE CODE 220
150.0
1 150.0
1
UNITS* Oa, GALLONS O b. CUBIC FEET O c. POUNDS Od. TONS zzt
1 DAYS ON SITE: 22z365.0
Check one item only) * If EHS, amount must be in pounds.
STORAGE
CONTAINER Oa, ABOVE GROUND TANK ❑e. PLASTIC/NONMETALLIC DRUM[] i. FIBER DRUM
❑m.
GLASS BOTTLE ❑q. RAIL CAR
❑b, UNDERGROUND TANK ❑ f. CAN ❑ j. BAG
PLASTIC BOTTLE ❑ r, OTHER
❑c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX
Hn.
o. TOTE BIN
❑d. STEEL DRUM ❑ It SILO ❑ I. CYLINDER
❑
p TANK WAGON 223
STORAGE PRESSURE O a. AMBIENT O b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE O a. AMBIENT O b ABOVE AMBIENT O c. BELOW AMBIENT Od. CRYOGENIC 225
%WT
HAZARDOUS COMPONENT (For mixture or waste only)
EHS
CAS #
I 226
227
❑Yes 228
229
2 230
231
❑Yes 232
233
3 234
235
❑ 236
237
4 238
239
❑Yes 240
241
5 242
243
❑Yes 244
245
ff more hazardous components are present at greater than t % by weight if non -carcinogenic, or 0.1% by weight if carcinogenic.:Mach .rdditionul ilmrt% of paper capturing the required information.
246
ADDITIONAL LOCALLY COLLECTED INFORMATION
UNIFIED PROGRAM CONSOLIDATED FORM
HAZARDOUS MATERIALS
HAZARDOUS MATERIALS INVENTORY — CHEMICAL DESCRIPTION
(one name Der material r building or areal
❑ADD ❑DELETE ❑REVISE 200 Page _ of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
PALIUS DRY CLEANERS
CHEMICAL LOCATION 201
CHEMICAL LOCATION CONFIDFNTiAL FPCR A 202
1
❑ YES
1
MAP# (optional) 203
GRID# (optional) 204
FACILITY ID #
F A 0 0 0 5 1 0 3
01
B2
11. CHEMICAL INFORMATION
CHEMICAL NAME 205
TRADE SECRET LJ Yes 206
Waste Hydrocarbon Filters
If Subject to EPCRA, refer to instructions
COMMON NAME 207
20s
EHS* ❑Yes
Waste Hydrocarbon Filters
CAS# 209
*If EHS is "Yes", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 210
Combustible Liquid, Class II (1.1 II)
HAZARDOUS MATERIAL 211
TYPE (Check one item only) Oa. PURE Ob MIXTURE Oc WASTE
RADIOACTIVE ❑Yes 212
213
CURIES
PHYSICAL STATE 214
(Check one item only) O a. SOLID Ob. LIQUID O c. GAS
215
LARGEST CONTAINER
55.0
FED HAZARD CATEGORIES - PHYSICAL FLAMMABLE [:]GAS UNDER PRESSURE EXPLOSIVE SELF HEATING
(check all that apply) ❑ PYROPHORIC ❑OXIDIZER [:]ORGANIC PEROXIDE []SELFREACTIVE ❑PYROHORIC GAS ❑CORROSIVE TO METAL
❑ CONTACT WATER EMITS FLAMMABLE GAS ❑COMBUSTABLE TO DUST ❑ HAZARD NOT OTHERWISE CLASSIFIED
FED HAZARD CATEGORIES - HEALTH: ❑CARCIGONECITY ❑ ACUTE TOXICITY ❑ REPRODUCTIVE TOXICITY []SKIN CORROSION OR IRRITATION
(check all that apply) ❑ RESPIRATIORY OR SKIN SENSITIZATION ❑ SERIOUS EYE DAMAGE OR EYE IRRIATIION ❑ SPECIFIC'I'ACiI '1' URUAN "l'OXICI'I'Y
❑ ASPIRATION HAZARD ❑ GERM CELL MUTAGENICITY ❑ SIMPLE ASPHYXIANT ❑ HAZARD NOT OTHERWISE CLASSIFIED
AVERAGE DAILY AMOUNT 217
MAXIMTiM DATT,Y AMOIFNT 21s
ANNIFAI, WASTE AMOUNT 219
STATE WASTE CODE 220
55.0
1 55.0
55.0
zzl
UNITS* Oa. GALLONS O b. CUBIC FEET O c. POUNDS Od. TONS
DAYS ON SITE: 222
365.0
(Check one item only) * If EHS autouut must be iu liomids.
STORAGE
CONTAINER —1,,. ABOVE GROUND TANK ❑e. PLASTIC/NONMETALLIC DRUM[]i. FIBER DRUM
[]an.
GLASS BOTTLE ❑q. RAIL CAR
❑b. UNDERGROUND TANK ❑ f. CAN ❑ j, BAG
PLASTIC BOTTLE ❑ r. OTHER
❑c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k BOX
Hn.
o. TOTE BIN
Rld. STEEL DRUM ❑ h SILO ❑1. CYLINDER
❑
p. TANK WAGON 223
STORAGE PRESSURE O a. AMBIENT O It ABOVE AMBIENT O c. BELOW AMBIENT 224
STORAGE TEMPERATURE O a. AMBIENT O b. ABOVE AMBIENT O c. BELOW AMBIENT Od CRYOGENIC 225
%WT
HAZARDOUS COMPONENT(For mixture or waste only)
EHS
C;AS #
1 75.0 226
Aluminum Housing 227
❑Yes 228
229
2 20.0 230
Fiber Filter 231
❑Yes 232
233
3 5.0 234
Hydrocarbon Residue 235
❑ 236
237
4 238
239
1:1Yes 240
241
5 242
243
❑Yes 244
245
If more hazardous components are present at greater than I % by weight if non -carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information.
246
ADDITIONAL LOCALLY COLLECTED INFORMATION